Some of spine surgery’s most familiar assumptions are becoming less certain.
As motion preservation expands, technology accelerates and the economics of practice shift, surgeons are reconsidering ideas that once seemed relatively settled, from whether fusion should always be avoided to whether good outcomes alone are enough for a new technique to take off.
Here are six assumptions spine surgery is starting to question:
1. Fusion should be avoided whenever possible: Spine surgeons have more ways than ever to preserve motion, but the ability to avoid fusion does not always mean it is the better operation.
Farah Musharbash, MD, a spine surgeon at Atlantic Brain and Spine in Morristown, N.J., told Becker’s he increasingly uses endoscopic, minimally invasive and motion-preserving approaches. Still, his revision practice has exposed him to the consequences when an earlier operation does not adequately address the underlying pathology.
“To me, a fusion is sort of the last resort,” Dr. Musharbash said. “But many times, it’s the right thing to do.” The emerging question is no longer simply whether surgeons can avoid fusion, but whether doing so actually solves the patient’s problem.
2. Bigger reconstruction means more progress: Spine surgery has become increasingly capable of correcting severe deformities. Kristen Jones, MD, associate professor of neurosurgery and orthopedic surgery at Durham, N.C.-based Duke University Health System, is interested in a different measure of progress: preventing more patients from reaching the point where they need those operations.
Even relatively small procedures can shape a patient’s alignment and degeneration years later, making decisions during an initial operation consequential well beyond the immediate problem. “The smallest thing we can do to make the biggest positive impact isn’t always a big surgery,” Dr. Jones told Becker’s.
For a field that has spent years expanding what surgeons can reconstruct, the next advance may be measured partly by how often those reconstructions can be prevented.
3. More technology means a better operation: Navigation, robotics, AI and patient-specific planning are giving spine surgeons unprecedented precision. Greater technical capability, however, does not automatically translate into a better outcome.
Dean Chou, MD, chief of spine surgery at New York City-based Columbia University Vagelos College of Physicians and Surgeons, said new technology has to clear a more fundamental test.
“Is it just a new widget because it’s new, or is it actually efficacious?” Dr. Chou told Becker’s.
For Dr. Chou, innovation has to improve on the alternative and ultimately make a meaningful difference for the patient, not simply make an operation newer or more technologically sophisticated.
4. Orthopedic and neurosurgical spine are fundamentally different worlds: For generations, becoming a spine surgeon began with one of two pathways: orthopedic surgery or neurosurgery.
Jeffrey Mullin, MD, a neurosurgeon at Williamsville, N.Y.-based University at Buffalo Neurosurgery, sees those worlds increasingly converging as surgeons treat many of the same conditions, use similar technologies and work together in professional societies and complex spine programs.
“We’re more alike than we aren’t,” Dr. Mullin told Becker’s. He can even envision a future in which spine develops its own training pathway. The orthopedic-neurosurgical distinction may remain, but the field is increasingly defining surgeons by what they practice rather than where they started.
5. A promising technique will spread if the outcomes are good: Endoscopic spine surgery is challenging that assumption.
Eighteen spine surgeons told Becker’s why adoption remains relatively slow in the U.S. despite growing interest in the technique. Surgeons repeatedly pointed to reimbursement, institutional support, training and the economics of the learning curve.
Saqib Hasan, MD, a spine surgeon at Golden State Orthopedics and Spine in Oakland, Calif., put the divide succinctly: “The West is falling behind not technically, but structurally.”
The experience suggests evidence and patient outcomes are only part of what determines whether an innovation becomes mainstream. The economics surrounding a procedure can be just as consequential.
6. Accepting Medicare is simply part of practicing spine surgery: Medicare participation has long been treated as a given for many surgeons. Continued reimbursement erosion is making that assumption less certain.
A Becker’s poll of 112 respondents found 53% said further payment cuts would be the factor most likely to make them reconsider Medicare participation. Some spine surgeons have already opted out.
“The tipping point came when each Medicare patient became a net-net loss on each and every office visit,” Brian Gantwerker, MD, president of The Craniospinal Center of Los Angeles, told Becker’s.
A mass departure from Medicare has not occurred, but surgeons are increasingly discussing alternatives that once sat outside the mainstream, including limits on new Medicare patients, private-pay practices and hybrid models.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
